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Global Health, Infectious Disease, Public Health, Public Safety, Stanford News

Biosecurity experts discuss Ebola and related public health concerns and policy implications

Biosecurity experts discuss Ebola and related public health concerns and policy implications

ebola_081214

More than 1,800 people in the West African nations of Liberia, Sierra Leone and Guinea have contracted the Ebola virus since March and the death toll has surpassed 1,000, according to the latest figures from the World Health Organization. As the number of cases and death continue to climb many are concerned about what can be done to curtail the outbreak and the likelihood of it spreading to the United States.

In a Q&A recently published by the Center for International Security and Cooperation and The Freeman Spogli Institute for International Studies, Stanford biosecurity experts David Relman, MD, and Megan Palmer jointly answer these questions and others related to the public health concerns and policy implications if the outbreak. On the topic of broader lessons about the dynamics and ecology of emerging infectious diseases that can help prevent or respond to outbreaks now and in the future, they respond:

These latest outbreaks remind us that potential pathogens are circulating, replicating and evolving in the environment all the time, and human action can have an immense impact on the emergence and spread of infectious disease.

We are starting to see common factors that may be contributing to the frequency and severity of outbreaks. Increasing human intrusion into zoonotic disease reservoir habitats and natural ecosystems, increasing imbalance and instability at the human-animal-vector interface, and more human population displacement all are likely to increase the chance of outbreaks like Ebola.

The epicenter of this latest outbreak was Guéckédou, a village near the Guinean Forest Region. The forest there has been routinely exploited, logged, and neglected over the years, leading to an abysmal ecological status quo. This, in combination with the influx of refugees from conflicts in Guinea, Liberia, Sierra Leone, and Cote d’Ivoire, has compounded the ecological issues in the area, potentially facilitating the spread of Ebola. There seems to be a strong relationship between ecological health and the spread of disease, and this latest outbreak is no exception.

While forensic analyses are ongoing, unregulated food and animal trade in general is also a key factor in the spread of infectious diseases across large geographic regions. Some studies suggest that trade of primates, including great apes, and other animals such as bats, may be responsible for transit of this Ebola strain from Central to Western Africa.

Overall, Relman and Palmer remind the public, “It’s important that we not lose sight of more chronic, but less headline-grabbing diseases that will be pervasive, insidious long-standing challenges for Africa and elsewhere.”

Previously: Stanford global health chief launches campaign to help contain Ebola outbreak in Liberia and Health workers use crowdsourced maps to respond to Ebola outbreak in Guinea
Photo by European Commission DG ECHO

From August 11-25, Scope will be on a limited publishing schedule. During that time, you may also notice a delay in comment moderation. We’ll return to our regular schedule on August 25.

Global Health, Infectious Disease, Stanford News

Stanford global health chief launches campaign to help contain Ebola outbreak in Liberia

Stanford global health chief launches campaign to help contain Ebola outbreak in Liberia

A Medical Officer at Lacor hospital in Gulu, 360 kilometers (224 miles) north of the Ugandan capital, Kampala examines a child suspected of being infected with the Ebola virus Tuesday, Oct.17, 2000. Only days after it was announced that an outbreak of Ebola, the world's most feared virus, had struck in northern Uganda the death toll rose to 35 and according to health officials 38 other people have been affected by the virus. (AP Photo/Sayyid Azim)Michele Barry, MD, director of Stanford’s Center for Innovation in Global Health, has launched a fundraising campaign to help combat the Ebola outbreak in Liberia, which has claimed the life of a colleague who mentored residents in the Yale/Stanford Johnson & Johnson Scholars Program.

Samuel Brisbane, MD, was the first Liberian doctor to die in the outbreak, which the World Health Organization says is responsible for more than 700 deaths in West Africa and is by far the largest outbreak in the history of the disease. Brisbane was an internist who treated patients at the John F. Kennedy Memorial Hospital in the capital city of Monrovia, the country’s largest hospital. A second medical officer has become ill at the hospital, one of the sites for the scholars’ program, Barry told me.

Through the program, Brisbane mentored physicians from Stanford and other institutions who volunteer for six-week stints in resource-limited countries. He quarantined himself after showing signs of illness but died on July 26 after being transferred to a treatment center, Barry said.

Like HIV, the Ebola virus is spread through direct contact with blood or body fluids from an infected individual. Barry said Liberia is in desperate need of personal protective equipment for health care workers, such as masks, gowns and gloves, as well as trained personnel who can do contact tracing and isolation of infected individuals. The Ebola virus has a 21-day incubation period, during which time an infected individual can transmit the virus.

Barry joined an informal fundraising campaign with her colleagues on Tuesday to help Liberian health-care workers contain the spread of the disease, raising $11,000 in 48 hours. Today, she broadened the appeal in an e-mail sent to all Stanford medical school faculty.

Barry has had experience fighting Ebola in Uganda, where she said outbreaks have been limited by isolating patients in outdoor, tented hospitals and where physicians and nurses have had access to good protective gear. In the past, she said the disease typically has had “hot spots” that last a month and then subside.

But the latest epidemic, which has affected patients in Guinea, Sierra Leone and Nigeria, as well as Liberia, has followed a somewhat different path.

“I think we are doing a better job of taking care of patients and keeping them alive longer, so they become more viremic — meaning the virus has spread through their bloodstream — and more infectious,” she said. “And with globalization, there is more traffic across borders so spillover to other countries occurs.”

She said she does not see the disease as a major threat to the United States, where effective infection control methods are widespread.

“I think we need to be vigilant, but I don’t think there needs to be any true concern that this is going to spread to the United States,” she said. “There’s always a risk of a patient coming in unknown to the hospital, but we practice good universal precautions because we have the equipment and we’ve been trained to treat HIV.”

Donations to the health-care project can be made online here.

Photo, from 2000 outbreak in Uganda, by ASSOCIATED PRESS

Global Health, Nutrition, Research, Stanford News

Stanford researchers address hunger in new book on food security

Stanford researchers address hunger in new book on food security

riceA piece from Stanford’s Freeman Spogli Institute for International Studies notes how experts across campus are working together to address the complex global problem of hunger. A new book, The Evolving Sphere of Food Security (Oxford University Press, August), discusses the problem from numerous perspectives, including medicine, in its 14 chapters. The book’s editor, Rosamond Naylor, PhD, is director of the Center on Food Security and the Environment, which is housed jointly within the FSI and the Woods Institute for the Environment.

From the piece:

“This book grew out of a recognition by Stanford scholars that food security is tied to security of many other kinds,” said Naylor, who is also William Wrigley Senior Fellow at the Freeman Spogli Institute for International Studies and the Stanford Woods Institute for the Environment. “Food security has clear connections with energy, water, health, the environment and national security, and you can’t tackle just one of those pieces.”

Stanford has a long history of fostering cross-disciplinary work on global issues. It is in this spirit that the idea for the book was born, Naylor said. The book weaves together the expertise of authors from the fields of medicine, political science, engineering, law, economics and climate science.

A recurring theme throughout the book – also reflected in its title – is the evolving nature of the food security challenges countries face as they move through stages of economic growth. At low levels of development, countries struggle to meet people’s basic needs. For example, Naylor’s chapter on health, co-authored with Eran Bendavid [MD] (medicine), Jenna Davis [PhD] and Amy Pickering [PhD] (civil and environmental engineering), describes a recent study showing that poor nutrition and rampant disease in rural Kenya is closely tied to contaminated, untreated drinking water. Addressing these essential health and sanitation issues is a key first step toward food security for the poorest countries.

Previously: Seeking solutions to childhood anemia in ChinaWho’s hungry? You can’t tell by lookingCould a palm oil tax lower the death rate from cardiovascular disease in India? and Foreign health care aid delivers the good
Photo by Thomas Wanhoff

Global Health, Medicine and Literature, Stanford News

Exploring global health through historical literature

Exploring global health through historical literature

deskPhysician-authors, including Abraham Verghese, MD, and efforts such as Stanford’s Arts, Humanities and Medicine Program draw the general public’s attention to issues important to the medical field. They may also elicit reader empathy by discussing real-world problems, even in fictional contexts, while situating literature and the arts in an influential position.

This relationship between medicine and literature is longstanding and complex. A Stanford News article discusses some examples of public health and humanism in historical literature and profiles the work of Alvan Ikoku, MD, PhD, an Andrew W. Mellon Fellow in the Humanities at Stanford.

From the piece:

As a scholar of 19th- and 20-century movements in international literature and health, [Ikoku] studies the place of long narrative forms, especially novels, in the development of tropical medicine and global health.

In his current book project, Forms of Global Health, Ikoku reads not Dickens or Gaskell, but writers such as Joseph Conrad and Andre Gide, who added to a “library of metaphors about the tropics and colonial spaces,” one that was referenced by “the fathers of tropical medicine” – returnees from colonial medical services, particularly malariologists, who wrote and lectured publicly about the need to establish a new medical specialty for the colonies.

Ikoku points out that literature provided an opportunity for readers to not simply feel an emotion, but to also actively help define a medical field and its knowledge base.

The article notes that Ikoku taught a course for Stanford students from many disciplines this spring called “The Literature of Global Health,” examining “how literary and medical writers have used narrative to explore the ethics of care in the developing world.”

Previously: Thoughts on the arts and humanities in shaping a medical careerMedical students and author Khaled Hosseini share their muse with Stanford community and Intersection of arts and medicine a benefit to both, report finds
Photo by Ben Sutherland

Global Health, Public Health, Stanford News

NIH Director “particularly impressed by the practicality” of Stanford-developed Foldscope

During the White House’s first-ever Maker Faire, Francis Collins, MD, director of the National Institutes of Health, was among those vying for a chance to test out a Foldscope, the 50-cent origami microscope invented by Stanford bioengineer Manu Prakash, PhD. In a post published yesterday on his blog, Collins said, “While I saw many amazing inventions and met many incredible inventors at this event, I came away particularly impressed by the practicality of this device and the ingenuity of its maker.”

Collins goes on to explain the design components of the Foldscope, his experience testing out the device and Prakash’s plans to open up the wonders of the microscopic world to future generations of scientists and engineers. He writes in the piece:

So, how do you use the Foldscope? It turns out that this bookmark-size device uses the same glass slides that one uses in a regular microscope. So, the preparation of blood or tissue samples remain the same. In the simplest version of the scope, the slide is inserted between the microscope’s paper layers and the user, with a thumb and forefinger grasping either end of the microscope strip, holds the lens close to one eye and flexes the strip to find the target object and bring it into focus. I had the chance to try this at the White House event, and found that learning how to use it is very easy. In more advanced versions, the device can project the image onto a wall or any other flat surface—a great, low-cost tool for educating healthcare workers and others in low-income nations about various infectious diseases.

Prakash is currently fine-tuning Foldscopes so they can be field tested in Ghana, Uganda, Nigeria, and Peru for diagnosis of malaria, microfilariasis, leishmaniasis, schistosomiasis, and sleeping sickness. His team at Stanford is also busy designing Foldscopes to help diagnose 30 other diseases, and drawing up plans for a next generation of Foldscopes that will utilize microfluidic components rather than glass slides—a step that should make sample collection and analysis even easier.

Not only will Foldscope give healthcare workers around the globe better ways to detect, and thereby treat, disease, it will also place magnifying power within the reach of all the world’s students, enabling them to ask and answer a great many scientific questions. To this end, Prakash has launched the Ten Thousand Microscopes Project to entice inquiring minds to beta test these devices and design experiments that can then be compiled into a crowd-sourced microscopy text. Imagine a world in which every kid carries around a 50-cent portable microscope, and brings science out of the lab and into real-world biology.

Previously: Manu Prakash on how growing up in India influenced his interests as a Maker and entrepreneur, Dr. Prakash goes to Washington and Stanford microscope inventor invited to first White House Maker Faire and The pied piper of cool science tools

Global Health, Health Disparities, Pregnancy, Research, Women's Health

In poorest countries, increase in midwives could save lives of mothers and their babies

In poorest countries, increase in midwives could save lives of mothers and their babies

midwifeThe World Health Organization reports that most maternal deaths are preventable; yet, preterm birth complications rank among the top 10 causes of death in low- and lower-middle-income countries. Two recent studies from the Johns Hopkins Bloomberg School of Public Health have explored the role skilled midwives may play in saving the lives of women and their babies in poor counties.

In one study, published in The Lancet, researchers found that deploying a small number of midwives – 10 percent more every five years through 2025 – in the world’s 26 poorest countries could stave off a quarter of the maternal, fetal and infant deaths there.

From a release:

The estimates were done using the Lives Saved Tool (LiST), a computer-based tool developed by Johns Hopkins Bloomberg School of Public Health researchers that allows users to set up and run multiple scenarios to look at the estimated impact of different maternal, child and neonatal interventions for countries, states or districts. For this analysis, the tool compared the effectiveness of several different alternatives including increasing the number of midwives by varying degrees, increasing the number of obstetricians, and a combination of the two.

In the other study, published in PLOS One, researchers used the LiST tool in the world’s 58 poorest countries, where they found that 7 million maternal, fetal and newborn deaths will occur between 2012 and 2015. The release continues:

If a country’s midwife access were to increase to cover 60 percent of the population by 2015, 34 percent of deaths could be prevented, saving the lives of nearly 2.3 million mothers and babies.

The researchers say boosting coverage of midwives who provide family planning as well as pregnancy care to 60 percent of women would cost roughly $2,200 per death averted as compared to $4,400 for a similar increase in obstetricians. Midwives are cheaper to train and can handle interventions needed during uncomplicated deliveries, while obstetricians are needed when surgical interventions such as cesarean sections are necessary, [lead author Linda Bartlett, MD] says. Midwives can administer antibiotics for infections and medications to stimulate or strengthen labor, remove the placenta from a patient having a hemorrhage as well as handle many other complications that may occur in the mother or her baby.

Previously: Indonesia’s cash transfer programs are valuable, Stanford health fellow findsStudy cautions babies born at home may be at increased risk for health problemsSimple program shown to reduce infant mortality in African country and Should midwives take on risky deliveries?
Photo by Vinoth Chandar

Global Health, In the News, Pediatrics, Public Safety, Sexual Health, Women's Health

Stanford research shows rape prevention program helps Kenyan girls “find the power to say no”

Stanford research shows rape prevention program helps Kenyan girls "find the power to say no"

The San Francisco Chronicle has a great story today about a collaborative project that is reducing rape and sexual assault of impoverished girls in Kenya.

The story highlights the combined efforts of activists Jake Sinclair, MD, and his wife, Lee Paiva Sinclair, who founded nonprofit No Means No Worldwide to provide empowerment training to Kenayn girls, and the Stanford team that has been analyzing the results of their efforts. As we’ve described before, this work is a great example of the academic chops of Stanford experts’ being combined with on-the-ground activism to make a difference for an urgent real-world problem.

As the article explains:

The girls and hundreds of others like them have participated in a rape-prevention workshop created by Jake Sinclair and Lee Paiva, a San Francisco doctor and his artist wife who have been working in Kenya for 14 years.

Their program is working, and that’s not just according to the dozen or so testimonials online, the couple said. Two studies out of Stanford – one published in April this year, one the year before – have found that girls who have gone through the couples’ classes experience fewer sexual assaults after the workshops.

More telling, perhaps: More than half of the girls report using some tool they learned from the classes to protect themselves, from kicking a man in the groin to yelling at someone to stop.

“It’s great to see the girls just find their voice, to find the power to say ‘no,’ ” Sinclair said. “It’s so enlightening. You can see it in their eyes, that something’s changed.”

Stanford research scholar Clea Sarnquist, DrPH, who has played an important role in the project, adds:

“A lot of these girls are using voice and verbal skills first,” Sarnquist said. “That’s one of the key things, is teaching the girls that they have the right to protect themselves – that they have domain over their own bodies, and they have the right to speak up for their own self interest.”

The whole story is definitely worth a read.

Previously: Empowerment training prevents rape of Kenyan girls and Self-defense training reduces rapes in Kenya

Big data, Global Health, Infectious Disease, Videos

Discussing the importance of harnessing big data for global-health solutions

Discussing the importance of harnessing big data for global-health solutions

The 2014 Big Data in Biomedicine conference was held here last month, and interviews with keynote speakers, panelists, moderators and attendees are now available on the Stanford Medicine YouTube channel. To continue the discussion of how big data can be harnessed to benefit human health, we’ll be featuring a selection of the videos this month on Scope.

At this year’s Big Data in Biomedicine conference, Michele Barry, MD, FACP, senior associate dean and director of the Center for Innovation in Global Health at Stanford, moderated a panel on infectious diseases. During the discussion, she raised the point that the lines between infectious disease and non-communicable disease are becoming increasingly blurred.

In the above video, Barry expands on this point and offers her point of view on the role big data can play in advancing global health solutions. “Big Data is clearly important these days to get a larger picture of population health,” say says. “What I’m concerned about, and would love to see happen, is for big data surveillance to happen in developing countries and under-served areas, particularly in Sub-Saharan Africa.” Watch Barry’s interview to understand how harnessing big data to improve preventative care for large populations could benefit all of us.

Previously: Stanford statistician Chiara Sabatti on teaching students to “ride the big data wave”, Using Google Glass to help individuals with autism better understand social cues, Rising to the challenge of harnessing big data to benefit patients and U.S. Chief Technology Officer kicks off Big Data in Biomedicine

Evolution, Genetics, Global Health, Public Health, Research, Stanford News

Melting pot or mosaic? International collaboration studies genomic diversity in Mexico

Melting pot or mosaic? International collaboration studies genomic diversity in Mexico

6626429111_df791cbb8d_zMexico is a vast country with a storied past. Indigenous Native American groups across the country maintain their own languages and culture, while its cosmopolitan residents of large cities are as globally connected as anywhere on Earth. But Mexicans and Mexican Americans are usually lumped together as “Latinos” for the purposes of genetic or medical studies.

Now an international collaboration headed by Stanford geneticist Carlos Bustamante, PhD, and the University of California, San Francisco pulmonologist and public-health expert Esteban Burchard, MD, MPH, has assessed the breadth and depth of genomic diversity in Mexico for the first time. Their work was published today in Science. As I explain in our release:

The researchers compared variation in more than 1 million single nucleotide polymorphisms, or SNPs, among 511 people representing 20 indigenous populations from all over Mexico. They compared these findings with SNP variation among 500 people of mixed Mexican, European and African descent (a category called mestizos) from 10 Mexican states, a region of Guadalajara and Los Angeles, as well as with SNP variation among individuals from 16 European populations and the Yoruba people of West Africa.

The researchers found that Mexico’s indigenous populations diverge genetically along a diagonal northwest-to-southeast axis, with differences becoming more pronounced as the ethnic groups become more geographically distant from one another. In particular, the Seri people along the northern mainland coast of the Gulf of California and a Mayan people known as the Lacandon found near the country’s southern border with Guatemala are as genetically different from one another as Europeans are from Chinese.

Surprisingly, this pattern of diversity is mirrored in the genomes of Mexican individuals with mixed heritage (usually a combination of European, Native American and African):

Consistent with the history of the Spanish occupation and colonization of Mexico, the researchers found that the European portion of the mixed-individuals’ genomes broadly corresponded to that of modern-day inhabitants of the Iberian Peninsula. The Native American portion of their genomes, however, was more likely to correspond to that of local indigenous people. A person in the Mexican state of Sonora, for example, was likely to have ancestors from indigenous groups in the northern part of the country, whereas someone from Yucatan was more likely to have a southern native component in their genome, namely Mayan.

“We were really fascinated by these results because we had expected that 500 years of population movements, immigration and mixing would have swamped the signal of pre-Columbian population structure,” said Bustamante

Finally, the researchers found that the origin of the Native America portion of an individual’s genome affected a clinical measure of lung function abbreviated FEV1:

The researchers drew on data that calculated the predicted normal FEV1 for each subject based on age, gender, height and ethnicity (in this case, the reference was a standard used for all people of Mexican descent). To understand implications of these results within Mexico, they modeled the predicted lung function across Mexico, accounting for differences in local Native American ancestry for a large cohort of mestizos from eight states. The model predicts a marked difference across the country, with the average predicted FEV1 for a person from the northern state of Sonora and another from the state of Yucatan differing by about 7.3 percent. (That is, the population from Sonora has predicted values that were slightly higher than the average for the country, and those from the Yucatan were slightly lower.)

“There’s a definite predicted difference that’s due only to an individual’s Native American ancestry,” said Gignoux. “Variations in genetic composition clearly give a different physiological response.”

The researchers emphasize that a lower FEV1 does not necessarily mean a particular ethnic group has impaired lung function. Disease analysis takes place in the context of standardized values of matched populations, and the study points out how it is necessary to match people correctly to their ethnic backgrounds before making clinical decisions.

Stanford’s Andres Moreno Estrada, MD, PhD, and Christopher Gignoux, PhD, share first authorship of the study with Juan Carlos Fernandez Lopez, a researcher at Mexico’s National Institute of Genomic Medicine.

Previously: Roots of disease may vary with ancestry, according to Stanford geneticist, Recent shared ancestry between southern Europe and North Africa identified by Stanford researchers, and Caribbean genetic diversity explored by Stanford/University of Miami researchers
Photo by DL

Global Health, Microbiology, Nutrition, Pediatrics, Research

Malnourished children have young guts

Malnourished children have young guts

Bangladeshi_childrenChildren who grow up malnourished lag behind healthy kids in terms of their height and weight. But a new study finds that they also fall behind in the bacteria in their guts. The findings may explain why weight gains are often temporary, and malnourished children remain underweight compared to healthy children in the long-term.

Babies get their first gut bacteria from their mothers during birth. As they eat new foods, the community that live in the intestines changes and matures throughout the first few years of life. By age three, an “adult” community has taken up residence in the gut, and helps the body to break down food and boost the immune system. But in malnourished children, scarce or low-quality food and infections from poor sanitation result in an underdeveloped bacterial community that looks more like the inhabitants of a young child.

A study by Sathish Subramanian and colleagues published yesterday in Nature finds that children living in a slum in Dhaka, Bangladesh who were treated for malnutrition with nutrient-dense foods, have a temporary improvement in their gut bacteria. But the community will regress back to a younger state months after the therapy stops. The results correlate with observations that nutritional therapy saves lives, but cannot correct problems such as stunted growth, learning disabilities and a weakened immune system.

Initially, the researchers took stool samples from healthy children of a range of ages from the same slum. By looking at the identity of the bacteria from their intestines, the researchers could figure out what types of bacteria live in the gut at different times. They then looked at the bacterial communities from children receiving therapeutic foods to treat malnutrition to determine the “age” of their communities throughout the course of their treatment.

In a commentary on the study, Elizabeth Costello, PhD, and David Relman, MD, researchers in the Department of Microbiology and Immunology at Stanford, compare the gut communities of malnourished children to a degraded environment, such as a clear-cut rainforest that becomes choked with weeds. Just as it is difficult to clear the weeds and restore the original rainforest trees, it is challenging to rehabilitate the gut communities of chronically malnourished children.

“Degraded communities can be resistant or resilient to change, and although host health can be restored, youth cannot,” write Costello and Relman. “Thus, an ounce of prevention is likely to be worth a pound of cure and, as with other types of developmental delays, early intervention may be crucial.”

The study’s authors suggest that monitoring the gut communities of impoverished children may be one way to kept tabs on their health, and to measure if experimental nutritional treatments are working. Just like height or weight, the age of the gut bacterial community may be one way to track a child’s growth and development.

Patricia Waldron is a science writing intern in the medical school’s Office of Communication & Public Affairs.

Previously: Malnourished infants grow into impoverished adults, study shows and Who’s hungry? You can’t tell by looking
Photo by Mark Knobil

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